7.3 Return-to-Work Criteria for the Big Six
Key Takeaways
- Symptom-only vomiting or diarrhea with no Big Six diagnosis: reinstate after at least 24 hours asymptomatic, or with written medical documentation of a noninfectious cause (2-201.13(A)(1)). That is the only symptom row a PIC clears alone.
- Every diagnosed Big Six reinstatement requires Regulatory Authority approval — paragraphs (B) through (G) of 2-201.13 each begin with it.
- Learn the four clocks and do not swap them: 24 hours symptom-only, more than 48 hours for norovirus, more than 7 calendar days for Shigella and STEC, and more than 30 calendar days for nontyphoidal Salmonella.
- The laboratory option is 2 consecutive negative results taken at least 24 hours apart and not earlier than 48 hours after antibiotics stop; the Supplement to the 2022 Food Code replaced "stool specimen cultures" with validated-test results from an accredited or certified laboratory, which allows culture-independent diagnostic tests.
- Salmonella Typhi and hepatitis A or jaundice have no time-only path: typhoid needs RA approval plus medical documentation, and hepatitis A needs RA approval plus jaundice more than 7 days, anicteric symptoms more than 14 days, or medical documentation.
Sending someone home is only half of employee health. FDA Food Code 2-201.13 is the other half: when the PIC may remove an exclusion or a restriction. CFPM exams test a short list of reinstatement rules. They do not test a single made-up national “stay home three days” number. Where the Food Code requires Regulatory Authority (RA) approval, the PIC does not freelance.
Two principles sit over the whole table:
- Symptom-only vomiting or diarrhea (no Big Six diagnosis) has a short, PIC-administered clock.
- Jaundice, hepatitis A, and Salmonella Typhi are never cleared by the PIC alone.
Symptom-Only Vomiting or Diarrhea
If the employee was excluded for vomiting or diarrhea and has no Big Six diagnosis, the usual Food Code options are:
- The employee has been asymptomatic for at least 24 hours, or
- A health practitioner provides written medical documentation that the person is free of the infectious agent or that the symptom comes from a noninfectious condition
“Asymptomatic” means no vomiting and no diarrhea. Feeling energetic after loperamide while the diarrhea is only suppressed is not 24 hours symptom-free. Local codes can be longer. The exam-facing number for this row is 24 hours, and it applies only when there is no Big Six diagnosis attached.
Norovirus Diagnosis
Reinstatement after a norovirus diagnosis runs through 2-201.13(D), and that paragraph opens with a condition candidates skip: the PIC must obtain approval from the Regulatory Authority and meet one of three options —
- more than 48 hours have passed since the employee became asymptomatic, or
- more than 48 hours have passed since diagnosis if the employee never developed symptoms, or
- written medical documentation from a health practitioner that the employee is free of a norovirus infection.
Before that, 2-201.13(A)(2) governs the step down: an employee who is asymptomatic for at least 24 hours in a non-HSP operation is restricted — not reinstated — until a (D) option is met, while the same employee in an HSP operation stays excluded. So the diagnosis does two things: it lengthens the clock from 24 hours to 48, and it puts the health department in the decision. Do not send a diagnosed norovirus case back to the salad station at the 24-hour symptom-only mark.
STEC or Shigella
Shigella spp. reinstatement is 2-201.13(E); STEC reinstatement is 2-201.13(F). Both paragraphs read the same way, and both require Regulatory Authority approval plus one of three options:
- more than 7 calendar days since the employee became asymptomatic, or
- more than 7 calendar days since diagnosis if the employee never developed symptoms, or
- written medical documentation that the employee is free of the infection, based on 2 consecutive negative laboratory results taken not earlier than 48 hours after antibiotics were discontinued and at least 24 hours apart.
The Supplement to the 2022 Food Code rewrote that third option. Where the 2022 base text said "2 consecutive negative stool specimen cultures," the Supplement substitutes "2 consecutive negative laboratory test results from a validated test, using a laboratory accredited or certified to handle clinical specimens" in sub-paragraphs (E)(1), (F)(1), and (G)(1). FDA's own note on the change says it replaces mandatory stool culture and allows culture-independent diagnostic tests (CIDTs) such as molecular or enzyme-based methods. The 48-hour and 24-hour specimen timing did not change.
As with norovirus, 2-201.13(A)(3) and (A)(4) handle the interim step: asymptomatic for at least 24 hours in a non-HSP operation means restricted, not reinstated; in an HSP operation the exclusion is retained until an (E) or (F) option is met.
Salmonella Typhi
Typhoid fever is not a PIC math problem. 2-201.13(C) gives no time-based option at all. Removing the exclusion requires both:
- Approval from the Regulatory Authority, and
- Written medical documentation from a health practitioner stating that the person is free from typhoid fever
A history of typhoid in the last three months without antibiotic therapy is a 2-201.11 reporting item. It is how recent carriers get flagged. The PIC who says "you have been out a week, come plate salads" has not reinstated a typhoid case. Only the RA plus a health practitioner can do that.
Nontyphoidal Salmonella
Nontyphoidal Salmonella (NTS) is the row study books get wrong most often, because its clock is far longer than every other Big Six number. Reinstatement is 2-201.13(G): RA approval plus one of
- more than 30 calendar days since the employee became asymptomatic, or
- more than 30 calendar days since diagnosis if the employee never developed symptoms, or
- written medical documentation based on 2 consecutive negative laboratory results (same 48-hour and 24-hour timing; the Supplement's validated-test language applies here too).
30 days is the Code number, not a rumor. Note where it appears twice: 2-201.13(A)(5)(a) restricts an employee who has been asymptomatic for at least 30 days until a (G) option is met, while (A)(5)(b) retains the full exclusion for an employee who is still symptomatic. A symptomatic NTS case therefore does not step down to restriction at 24 hours the way an undiagnosed stomach bug does.
Do not swap the clocks across rows. 24 hours is the symptom-only row. More than 48 hours is norovirus. More than 7 calendar days is Shigella and STEC. More than 30 calendar days is nontyphoidal Salmonella. Typhoid and hepatitis A have no time-only path a PIC can run alone.
Hepatitis A and Jaundice
Jaundice and hepatitis A are the other “PIC never clears this alone” row.
Under 2-201.13(B) the PIC may remove the exclusion only with Regulatory Authority approval, and only when one of these options is met:
- The person has been jaundiced for more than 7 calendar days, or
- The person had anicteric symptoms (hepatitis symptoms without jaundice) for more than 14 calendar days, or
- A health practitioner provides written medical documentation that the person is free of hepatitis A virus infection
Count the days of jaundice, not the days since the employee last worked. A cook who has been yellow for two days is not eligible under the 7-day option. Gloves do not shorten the calendar. The dish pit is not an alternative to RA approval.
The Reinstatement Table
| Condition | Control while out | Reinstatement rule the Code states | Code hook | RA approval? |
|---|---|---|---|---|
| Vomiting or diarrhea, no Big Six diagnosis | Exclude | Asymptomatic at least 24 hours, or written medical documentation that the symptom is from a noninfectious condition | 2-201.13(A)(1) | No (unless the local RA adds one) |
| Diagnosed norovirus | Exclude; step down to restrict at 24 hours asymptomatic in non-HSP, retain exclusion in HSP | More than 48 hours asymptomatic, or more than 48 hours since diagnosis if never symptomatic, or medical documentation free of norovirus | 2-201.13(A)(2), (D) | Yes |
| Diagnosed Shigella spp. | Exclude; restrict at 24 hours asymptomatic in non-HSP, retain exclusion in HSP | More than 7 calendar days asymptomatic, or more than 7 days since diagnosis, or medical documentation from 2 consecutive negative validated laboratory results taken at least 48 h after antibiotics and at least 24 h apart | 2-201.13(A)(3), (E) | Yes |
| Diagnosed STEC | Same structure as Shigella | Same three options as Shigella | 2-201.13(A)(4), (F) | Yes |
| Diagnosed nontyphoidal Salmonella | Retain exclusion while symptomatic; restrict once asymptomatic at least 30 days | More than 30 calendar days asymptomatic, or more than 30 days since diagnosis, or medical documentation from 2 consecutive negative validated laboratory results | 2-201.13(A)(5), (G) | Yes |
| Diagnosed Salmonella Typhi (typhoid) | Exclude | No time-only option. RA approval and medical documentation that the person is free from typhoid fever | 2-201.13(C) | Yes |
| Jaundice or diagnosed hepatitis A | Exclude | Jaundiced more than 7 calendar days, or anicteric symptoms more than 14 calendar days, or medical documentation free of HAV | 2-201.13(B) | Yes |
| Sore throat with fever | Restrict (exclude in HSP) | Medical documentation of more than 24 hours of antibiotic therapy for Streptococcus pyogenes, or a negative throat specimen culture, or that the person is otherwise free of the infection | 2-201.13(H) | No — medical documentation is the path |
| Infected wound, now properly covered | Restrict until covered | Restriction ends when an impermeable cover is in place, plus a single-use glove if the lesion is on a hand or wrist | 2-201.12 / 2-401.11 conditions | No |
Every diagnosed Big Six condition needs the health department. Paragraphs (B) through (G) of 2-201.13 each begin with the PIC obtaining approval from the Regulatory Authority. The only rows a PIC clears alone are the symptom-only row, the sore-throat row, and the covered-wound row.
What the PIC Must Not Do
PIC never clears jaundice or typhoid alone
The PIC never “clears” jaundice or typhoid with a hallway conversation. The PIC does not accept a text message from a roommate. The PIC does not trade a 24-hour stomach-bug clock for a hepatitis A case. The PIC does not let a cook self-certify after two negative home tests of unknown quality.
The PIC does keep the report, the onset date, whether a diagnosis arrived, whether the facility is HSP, and whether the RA was notified. That file is how 2-201.13 is applied on a Tuesday when the cook wants to come back.
Local health departments can require longer exclusions or different paperwork. Those variations are real and they are not unpublished trivia you should invent on a national CFPM item. When the stem names the Food Code, use the table above. When the stem says “the health department must approve,” the answer includes the RA.
A manager who wants people to report illness has to have a fair, written way back to work. The way back is 2-201.13, not a handshake.
A prep cook was excluded for vomiting and diarrhea and has no Big Six diagnosis. Under the usual Food Code / CFPM rule, when may the PIC consider reinstatement?
A cook who had jaundice wants to return to the line. Who may reinstate that employee under Food Code 2-201.13?
An excluded employee has a diagnosis of Shigella or STEC. Which return path matches the usual CFPM / Food Code 2-201.13 teaching?